CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

What the AHRQ guidance means for providers and their patients. 11

Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

New CPS report seeks to raise awareness of safety concerns in the EMS community. 16


  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

PSO 101: Introduction to PSOs

November 17 @ 12pm CST   – Free webinar

Questions and Answers signpostConfused about Patient Safety Organizations (PSOs)?   You’re not alone!

Join the experts at the Center for Patient Safety as they describe the basics of the Patient Safety and Quality Improvement Act (PSQIA) and provide an introduction to the terminology and concepts of PSO participation.  Applications to EMS, LTC, medical offices, and hospitals will be presented.   Q&A available during webinar.   Register

About Patient Safety Organizations (PSOs): Did You Know?

Now that Patient Safety Organizations (PSOs) have been in existence for more than five years, the federal Patient Safety and Quality Improvement Act (PSQIA) is better understood, and knowledge about the Act has increased. Still, there are a number of questions we commonly receive at the Center for Patient Safety.   Here are the top 10 questions, answered by the Center’s Patient Safety Specialist, Eunice Halverson at [email protected]:

Why should a health care provider join a PSO?
PSOs are independent, external experts who can collect, analyze and aggregate patient safety work product to develop insights into the underlying causes of patient safety events. Communications with PSOs are protected to allay fears of increased liability or fear of sanctions. With this federal protection, healthcare providers can share information with other participants, via the PSO, and learn from each other to ultimately improve patient care. More information is available from the AHRQ on working with a PSO.


Center releases Fall 2014 EMS PSO Newsletter

Fall EMS 2014The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more!   Download the newsletter or view on Issuu.

Mixed results from Kentucky Supreme Court

The Kentucky Supreme Court has issued its anxiously awaited opinion in Tibbs, et al. v. Bunnell (2012-SC-000603-MR). The opinion is available online here. Earlier in the case, the Kentucky Court of Appeals ruled that only work reflecting “self-examining analysis,” could be protected PSWP, eliminating data or reports used as part of that analysis from protection. The hospital appealed, with support from the national PSO community. The Kentucky Supreme Court rejected that restriction based on the language of the law and final rule.   It went on to examine the definition of PSWP as applied to the information sought by the plaintiff, which included incident reports. (more…)

PSOs Are Watching New Florida Decison about PSWP

A Florida trial court order regarding the discovery of hospital incident reports is circulating in PSO circles.   (Charles v. Southern Baptist Hosp. et al., Duyal County, Case No. 15-2012-CA-002677.)   The order expresses a very restrictive view of PSWP (more below) and the hospital has expressed an intention to appeal the order.   As a trial court order in Florida, it has no value as precedent in any other jurisdiction, even within Florida.   However, the order will be part of the ongoing discussion about PSO protections, so CPS wants its stakeholders to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.   The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP. (more…)

PSO? PSES? PSWP? You have questions, we have answers

Three-part National Webinar Series

PSO? PSES? PSWP? You have questions, we have answers hosted by the Center for Patient Safety (CPS) and VergeSolutions.

Remember that the Affordable Care Act requires hospitals with more than 50 beds to adopt a Patient Safety Evaluation System (PSES), which is accomplished by participating in a Patient Safety Organization (PSO).

The January 1, 2015 deadline requires qualified health plans that are part of the Health Insurance Exchange to contract only with those providers that have an established  PSES. We encourage you to identify a PSO and adopt your PSES by 1/1/2014 to avoid last-minute contracting and implementation of PSO participation.

Dr. Munier,  Director of the Center for Quality Improvement and Patient Safety, AHRQ, states in Part III: “I can’t think of a better way to move forward in the world of safety than working with your PSO.”

If you missed this helpful series, check out our online videos and downloadable material… (more…)

CPS Faculty for National Webinar Series

Part II, National Webinar Series, Scheduled October 16 at 1:00 PM CST!

The Center for Patient Safety staff will serve as faculty to answer more of your questions for Part II: PSOs? PSES? PSWP? You have questions, we have answers!   This Webinar will delve deeper into PSO processes and how to gain the most from PSO participation in Part II of this series, a follow up to the September 12th Part I Webinar (listen to the audio and/or watch the presentation).

In Part II you will learn more details about working with a PSO and setting up your processes to take the most advantage of PSO participation and the federal confidentiality protections that are available by working with a PSO.   A bonus included in Part II is an update on court challenges to the federal PSO protections.

We hope you will join us for this FREE Webinar held in partnership with Verge Solutions!.

Registration is available here!

PSO WATCH/ALERT! Need for Clear Policies and Educated Defense Counsel

New Kentucky Appeals Court Decision Underscores the Need for Clear Policies and Educated Defense Counsel

(Mercy Health Partners-Lourdes, Inc. v. Kaltenback, No. 2013-CA-000053-OA, entered July 11, 2013)

Download a printable version

The Center’s participants have heard us preach about defining clear boundaries for their Patient Safety Evaluation Systems (PSES) and implementing clear PSES policies.   Courts will examine these policies closely in determining whether information generated as part of patient safety activities can be protected as Patient Safety Work Product (PSWP).   They will also examine the path of purported PSWP to see if the organization has followed its own policies for protected information. (more…)

CPS Faculty for National Webinar Series: PSO? PSES? PSWP? You have questions we have answers!


The Center for Patient Safety staff has learned a lot about providers’ needs in working with a Patient Safety Organization (PSO) and setting up processes to gain the most out of PSO participation and related federal confidentiality and security provisions. We are now sharing this expertise nationally through a FREE Webinar Series, PSO? PSES? PSWP? You have questions, we have answers beginning Thursday, September 12 at 11:00 AM CST, in partnership with Verge Solutions!

The September 12 Webinar focuses on establishing a Patient Safety Evaluation System (PSES) and introducing Patient Safety Work Product (PSWP) to help providers better understand how to set up a PSES to best meet their needs, particularly in light of the pending January 2015 ACA requirement for larger hospitals to establish a PSES. If you want to learn more about PSOs, PSES and PSWP, please join us September 12th.

Registration is available here.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

Read More


The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.